Purpose of the study: Progressive excentration of the femoral head is fequent in the paralytic hip. The result can be dislocation with considerable functional impact even if the subject cannot walk. Once the dislocation becomes permanent,, treatment is difficult. Soft tissue surgery is insufficient. We present our experience with Chiari osteotomy in a series of 28 paralytic hips.

Material and methods: This retrospective analysis included 28 paralytic hips which were operated on from 1974 to 2003. Fourteen patients had cerebral palsy and 14 a cord lesion. Mean age was 18.5 years (range 9–48) at the time of hip surgery. Mean postoperative follow-up was ten years. Prior hip surgery was noted in eleven cases and association with other bone and joint deformities was frequent: scoliosis, oblique pelvis. The Buly classification was noted for patient independence and was ≤ 2 preoperatively for seven patients. Flexion was greater than 80°. Preopeartive excentration was scored according to Reimers: luxation for ten hips and subluxation for 18. Acetabular dysplasia was present in all patients and 19 presented coxa valga. The femoral head was deformed in 14. The objective of the operation was to relieve hip pain and improve hip motion with a good acetabular cover. A chisel was used in all cases for the osteotomy: average 12° ascending cut medially. Associated procedures were: release (n=7), posterior block (n=2), femoral varus osteotomy (n=6), derotation osteotomy (n=6).

Results and discussion: The effect was clearly beneficial in terms of pain relief. There were no stiff hips. No functional degradation was noted and there were no major complications. The Median Reimers index improved from 66% to 19%. Centering was perfect for nine patients and presented residual excentration > 30% for six. There were two cases of femoral head necrosis (on dislocated hips). Seven hips progressed to osteoarthritic degradation and one patient underwent a revision procedure at 14 years for a total hip arthroplasty.

Conclusion: Chiari osteotomy enabled pain relief and improved function in most patients. It stabilized the hip even after dislocation if appropriate procedures are associated. At present however, for dislocated hips, total hip arthroplasty is often proposed. An associated oblique pelvis and scoliosis should be corrected for before surgical treatment of the hip.

Purpose of the study: Old tears of the subscapular muscle situated in the glenoid area are not accessible to direct repair and require locoregional muscle plasty. The clavicular portion of the pectoralis major can be used for reconstruction. The purpose of this study was to describe the operative technique and examine short-term outcome.

Material and methods: Five patients, mean age 54 years (45–71 years) with an irreparable tear of the subscapularis in the glenoid area with fatty degeneration greater than grade two in the Goutallier classification were treated. Four had had previous surgery for acromioplasty associated with rotator cuff repair in two or implantation of a humeral prosthesis in one. The preoperative Constant score was 27.5 (mean, range = 8.5–54) due to invalidating pain, limited active mobility and reduced muscle force. Gerber’s lift-off test was positive for those patients for whom it could be performed. Plain x-rays evidenced anterior subdislocation of the humeral head in one case. Subscapular reconstruction was achieved using the entire clavicular portion of the pectoralis major which was dissected and sectioned at its distal insertion on the humerus then reinserted by transosseous suture onto the lesser tuberosity. The rehabilitation program started with active and passive mobility against gravity within a few days of surgery using biofeedback contraction of the muscle flap then active contractions two months postoperatively. Patients were reviewed at a mean 19 months (6–42 months) for clinical and radiological assessment.

Results: Four patients had a painless shoulder with a negative lift-off test. The gain in active mobility was predominantly achieved with anterior elevation and abduction. Muscle force was weak leading to a low overall Constant score at revision (mean = 50, range = 30–63). Radiographically, the humeral head was centered exactly as on the preoperative films. There were no cases with a new anterior subdislocation nor an aggravation of a former subdislocation. Functional outcome was better in cases with a unique tear of the subscapularis.

Discussion and conclusion: Open surgery is used for primary repair of recent tears of the subscapularis. This technique gives 80 p. 100 good and very good results. In case of symptomatic acromioclavicular osteoarthtisis, better long-term results can be obtained by using a tendodesis of the long biceps and resecting the lateral centimeter of the clavicle. In case of irreparable tears in the glenoid area, reconstruction by transfer of the clavicular portion of the pectoralis major can produce a stable painless shoulder with improved active moblity and normal clinical tests. This method provides anterior stability of the glenohumeral articulation and prevents any anterior subdislocation of the humeral head, thus protecting the joint from secondary degeneration.